Health Care Professionals

Frequently Asked Questions for Pharmacists

Overview

What has changed regarding the first stage of expanded professional pharmacy services?

Effective September 1, 2011, the first stage of expanded services in which a potential drug related problem is identified at the time of dispensing is renamed the Pharmaceutical OpinionProgram and will now include a clinical intervention identified by the pharmacist at the time of conducting a MedsCheck medication review.

What is the Pharmaceutical Opinion Program?

The first stage of expanded services, now referred to as the Pharmaceutical Opinion Program is a clinical intervention that occurs at the time of dispensing a prescription or when conducting a MedsCheck review when a pharmacist identifies a potential concern that requires follow-up with the prescriber. Based on consultation with the prescriber, the prescription may not be dispensed, may be dispensed as prescribed or the prescription therapy may be adjusted (includes adding or discontinuing a prescription).

Are all Ontario residents eligible for the Ontario government’s Pharmaceutical Opinion program?

Only Ontario Drug Benefit recipients are eligible for the pharmaceutical opinion program in Ontario.

What are the objectives of the pharmaceutical opinion program?

The objectives of the pharmaceutical opinion program include:

promoting healthier patient outcomes;

improving and optimizing drug therapy;

ensuring benefits are used appropriately; and

reducing inappropriate drug use and drug wastage.

What are the outcomes when a pharmacist initiates a pharmaceutical opinion?

When the pharmacist makes a recommendation to the prescriber in a pharmaceutical opinion, there are three possible outcomes:

Not Filled: The prescription is not filled as a result of a confirmed forgery or due to a clinical concern based on consultation with the prescriber.

No Change: Recommendations by the pharmacist were discussed with the prescriber and no change to drug therapy was made to the prescription or the patient’s profile. Prescription was filled as prescribed no change to MedsCheck profile (if applicable)

Change: Recommendations by the pharmacist were discussed with the prescriber and led to a change in therapy as prescribed.

Are pharmaceutical opinions identified by pharmacists when filling prescriptions something new in pharmacy practice?

No. Community pharmacists have historically contacted physicians regarding potential drug related problems that are identified at the time of dispensing a prescription. The ministry recognizes the value added benefits to patient drug therapy and patient safety as a result of a pharmacist’s clinical intervention and recommendation to the prescriber regarding the issues at hand.

Are clinical interventions identified when conducting a MedsCheck something new?

No. Community pharmacists on occasion identify potential drug related problems when conducting a MedsCheck and as a standard of care the pharmacist takes action by either working to resolve the issue or by referring the patient to the appropriate health care professional.

Why did the ministry introduce the first stage of expanded services now called the Pharmaceutical Opinion program?

In June 2010, the Minister of Health and Long-Term Care announced additional funding towards pharmacist’s professional services that included the MedsCheck expanded programs that were launched in September 2010 and the development of a special working group of community pharmacists to provide advice on professional pharmacy services that could be implemented in the near future. The first stage of expanded services was introduced on the recommendation of the special working group.

When was the first stage of expanded services implemented?

The first stage of expanded services was originally implemented on April 1, 2011 for potential drug related problems identified at the time of dispensing. The program was renamed, Pharmaceutical OpinionProgram and expanded to include clinical interventions identified when conducting a MedsCheck medication review effective September 1, 2011.

What is the amount paid by the ministry for the pharmaceutical opinion?

The amount paid to the pharmacy through the ministry’s Health Network System is $15 per applicable prescription in which the pharmacist identifies a drug related problem at the time of dispensing a new or repeat prescription and/or at the time of conducting a MedsCheck medication review.

Is there a payment to the physicians who are contacted by pharmacists?

No, the pharmaceutical opinionservice is a recognized pharmacist professional service.

Can a pharmacist bill the ministry for both a MedsCheck and a pharmaceutical opinion if a prescription is changed as an outcome of the MedsCheck?

Yes, effective September 1, 2011 the pharmaceutical opinionmay be claimed as a result of a pharmacist identifying a potential drug related problem resulting from a MedsCheck review.

Drug Related Problem (DRP)

What is a Drug Related Problem?

A drug related problem (DRP) – also referred to as a drug therapy problem – is an undesirable event or risk(s) experienced by the patient that involve or are suspected to involve drug therapy and that inhibit or delay him/her from achieving the desired goals of therapy1. The first stage of expanded services uses eight intervention criteria; the DRP identified during a MedsCheck review uses the first seven intervention criteria.

What are the Drug Related Problem categories associated with the first stage of expanded services?

The potential drug related problems that may be identified:

Therapeutic duplication; drug may not be necessary

Requires drug; needs additional drug therapy

Sub-optimal response to a drug

Dosage too low

Adverse drug reaction

Dangerously high dose; potential overuse; abuse

Non-compliance / Adherence

Confirmed forgery or falsified prescription

Are the Drug Related Problems further defined?

The Drug Related Problems are further defined in the detailed program information.

What if I identify a Drug Related Problem that is not on the list?

All patient problems involving medications can be categorized into one of the eight types of drug related problems outlined in the ministry’s first stage of expanded services. These include any and all side effects, toxic reactions, treatment failures, or the need for additive, synergistic, or preventative medications, as well as non-compliance.

If I am following up with the patient to determine if there are compliance issues or that the medication is working, which PIN should I use to submit a claim?

Provided a drug related problem is identified during the follow-up review whereby the pharmacist makes a recommendation to the physician on the drug therapy issue, the pharmacist may proceed with the appropriate outcome based on the program criteria. For example: If there are no changes to a patient drug therapy as a result of the discussion with the physician, the “no change” PIN should be used. If changes were recommended/made to therapy i.e., different product, strength or dosage form, adding a drug or discontinuing a drug, the PIN indicating that a change was made should be used.

During a MedsCheck review the pharmacist identifies that drug therapy should be used by the patient. For example, the patient requires a stool softener because he/she is taking an opioid prescription. Which PIN should be used to submit a claim?

In this situation the pharmacist should use the PIN for Change to Prescription Therapy as therapy is added.

During a MedsCheck review the pharmacist identifies a duplication of therapy, which PIN should be used to submit a claim under the pharmaceutical opinion program?

Confirmation with the prescriber regarding a duplication of therapy requires that a drug be discontinued. Should a drug be discontinued under the program, the PIN for Change to Prescription Therapy should be used.

In the course of reviewing a patient’s profile during a MedsCheck, the pharmacist ascertains that the patient may benefit from a vaccine. For example, the patient may be at high risk in developing pneumonia and may benefit from a pneumococcal vaccine. Is this a billable service under the pharmaceutical opinion program as adding drug therapy?

Yes. Provided the pharmacist follows through with the recommendation to the physician along with the required documentation this may be claimed as a billable service using the PIN for Change to prescription therapy.

Process

Where does a pharmaceutical opinion conducted by the pharmacist take place?

A pharmaceutical opinionoccurs in a community pharmacy at the time of dispensing a new or repeat prescription that is presented by the patient to the pharmacy staff. A pharmaceutical opinionmay also occur at the time of conducting a MedsCheck medication review. The location of MedsCheck medication reviews are outlined in the respective MedsCheck program materials.

When does a pharmacist contact the prescriber regarding a pharmaceutical opinion?

If the pharmacist identifies a potential drug related problem at the time of dispensing a new or repeat prescription he/she will contact the physician and make a recommendation regarding the drug therapy issue. Similarly, if a potential DRP is identified during the MedsCheck review, the pharmacist will contact the prescriber with the recommendation and collaborative outcome.

How is the pharmaceutical opinion communicated to the physician or prescriber?

Pharmacists may contact the prescriber as they would for any prescription related issue by telephone or by fax or other means that is considered appropriate and secure.

As a pharmacist, why am I required to make a recommendation to the physician in order to claim for a pharmaceutical opinion?

Expertise in medications and medication use is one of the four domains of a Canadian pharmacist’s standards of care2. Pharmacists who identify a potential drug related problem are therefore expected to provide a recommendation to the physician that is in the best interest of the patient’s drug therapy. Without a recommendation regarding drug therapy and documentation, the interaction does not meet the pharmaceutical opinionservice requirements.

What will happen if I forget to document the recommendation that I provided to the physician?

If there is no documentation or incomplete documentation regarding the pharmaceutical opinionprogram requirements, the claim is subject to recovery.

Is there a standardized form that is sent to the prescriber for the pharmaceutical opinion program?

No. While the ministry does not provide a standardized form for the pharmaceutical opinion program, pharmacists may develop their own form based on the in-depth documentation criteria outlined under the program requirements.

Can I accept the physician’s response to my recommendation verbally?

The pharmacist may accept the response from the physician over the phone and transcribe the required information unless the outcome is a change in drug therapy that requires a written prescription by law.

Am I required to contact the patient with the outcome?

Yes. The patient needs to know the outcome of the pharmaceutical opinionand the pharmacist is accountable for contacting the patient.

How much documentation does the pharmaceutical opinion require by the pharmacist?

Documentation must be on the patient’s electronic profile or on the prescription hardcopy and in a readily retrievable format or if applicable on the MedsCheck documentation. At a minimum, pharmacists must outline the outcome, the drug related problem, the recommendation to the prescriber and any other comments to substantiate the outcome. In addition, the date, the name of the prescriber that was contacted and the pharmacist’s signature are required.

What is required for record keeping for the pharmaceutical opinion program?

The original prescription (or copy) whether verbal or written, along with all signed and dated documentation must be maintained on site at the pharmacy in a readily retrievable format for a minimum of 2 years for the purposes of audit under the Ontario Drug Benefit program. The pharmaceutical opinionrecord is cross-reference to the prescription that it is aligned with.

How long must I keep the pharmaceutical opinion documentation information on file?

All records relating to the pharmaceutical opinionclaim and the prescription that it is cross-reference with (or the MedsCheck documents) are maintained on site at the pharmacy in a readily retrievable format for a minimum of 2 years for the purposes of audit under the Ontario Drug Benefit program. All patient health records must be retained by the pharmacist in a readily retrievable format and kept on file at the pharmacy for a minimum period of ten years or as per O.Reg. 58/11 of the Drug and Pharmacies Regulation Act.

How often may I conduct a pharmaceutical opinion?

A pharmaceutical opinion may be conducted as identified by the pharmacist for new or repeat prescriptions or as a result of conducting a MedsCheck review according to program criteria.

Do pharmacists require additional training to conduct a pharmaceutical opinion?

No. Pharmacists that are registered as Part A with the Ontario College of Pharmacists are qualified to conduct a pharmaceutical opinion.

Restrictions

Does calling the doctor to clarify a prescription qualify as a pharmaceutical opinion?

No, calling a prescriber to only clarify a prescription dose or dosage form or concentration does not meet the requirements of a pharmaceutical opinionfor reimbursement. In addition, contacting the prescriber due to missing information on a prescription, clarifying a patient’s contact information or the prescriber’s handwriting are also not applicable.

Can I claim a pharmaceutical opinion if I do not have the medication in my inventory and I ask the prescriber to change the prescription to something that I carry?

No. Contacting the prescriber to change the prescription to a product that is in your inventory is not considered a pharmaceutical opinion for reimbursement. A pharmaceutical opinion is a clinical recommendation based on a potential drug related problem and not based on whether the item is in stock.

The prescription was placed on hold in the pharmacy system as the patient does not require the prescription at the time of filling; can I claim a pharmaceutical opinion?

No. The act of placing the prescription on hold is not considered a pharmaceutical opinion for reimbursement.

The Health Network System indicates a “fill too soon” message for a prescription that was entered, am I allowed to claim for a pharmaceutical opinion?

No. Pharmacists are not eligible to receive a pharmaceutical opinionpayment for claims that are already captured through the Health Network System (HNS) including “fill too soon” or “too late”. However, if in addition to the HNS message alert the pharmacist made a valid recommendation to the prescriber that aligns with the pharmaceutical opiniondrug related problems, then it is valid.

The physician requested a patient medication profile, is this transaction something I can claim as a pharmaceutical opinion or as a MedsCheck?

No. Providing a patient profile or a list of medications to the prescriber without making a recommendation to the prescription is not considered a pharmaceutical opinionor a MedsCheck service for reimbursement.

I am being asked for a copy of the patient’s MedsCheck medication review, am I able to claim for a pharmaceutical opinion?

No. Providing a MedsCheck medication review to the prescriber without making a recommendation to the prescription is not considered a pharmaceutical opinion for reimbursement nor is it a billable service under the MedsCheck program.

The drug prescribed is not an eligible benefit for the patient’s drug plan coverage. Is contacting the physician to prescribe something that is an eligible benefit considered a pharmaceutical opinion?

No. Contacting the prescriber to change a medication to an eligible benefit is not considered a pharmaceutical opinionfor reimbursement.

During the MedsCheck review, the pharmacist identifies a change to drug therapy however, it happens to be a change from a non-eligible drug to an eligible benefit. While this is a program restriction, if there is clinical value to therapy is it a billable service?

Yes. Provided the pharmacist has undergone the appropriate steps in the program including documentation of the clinical value of the drug and what has occurred regarding the patient’s drug therapy, then the scenario mentioned would apply.

Pharmacist’s steps to take under this program:

A new or repeat Rx

A DRP that a pharmacist has identified

A recommendation to the MD regarding the issue

The communication exchange between MD and RPh

An outcome is achieved (one of 3)

Documentation of the issue including cross-reference to the prescription.

Appropriate follow-up with the patient

Can the pharmacist make a recommendation to the physician that a patient requires an aerochamber or another medical device as aiding drug therapy and bill this as a pharmaceutical opinion?

No. Areochambers, diagnostic test strips and other medical devices that are associated with drug therapy are not considered as meeting the program criteria of one of the seven drug related problems. In addition, medical devices are not defined as drugs or as natural health products by Health Canada.

Is there a list of situations that are not considered eligible for claiming a pharmaceutical opinion?

Yes, there is a list of what is not included in pharmaceutical opinion information however, the list is not inclusive. Please refer to the program information for more details.